Educating the Experts – Lesson Five: Schedules

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You can read the article in Hebrew here, thanks to Idan Melamed!

Up until now we’ve been focusing on infant responsiveness which is primarily linked to crying-it-out, or sleep, strategies.  However, we’re going to take a turn today and focus instead on the concept of routines or schedules.  Most of you are adamant advocates for the schedule.  Some of you are more strict than others, but you nearly all say that parents should instill a “routine” (really you mean “schedule”) starting at day one, most claiming that researchers and doctors state that children do better when they know what’s coming.  Quite expectedly, it’s not that simple.

First, most work on schedules (and the lack thereof) have been done with parents who have shift-work, meaning that there can be immense interruption in the child’s schedule[1], but even within these studies, there are factors that both mitigate the effects, such as having a second parent at home while one is at work to take care of the child[2], and that may explain the relationship outside of the nonstandard schedule, such as increased parental stress[1].  Second, some of the other work I’ve seen cited has to do with children with Autism Spectrum Disorders who are known to require structure and routines in order to thrive[3].  Third, most of this work is also done with older children, preschool age and above[1][2], limiting the generalizability to newborns, infants, and toddlers.  Finally, there’s also evidence that schedules that don’t leave room for flexibility and free time don’t aid a child’s socioemotional development[4].  Thus, the idea that our newborns require a schedule is not quite as clear as you would like parents to believe.  I will say that there is nothing inherently wrong with having a schedule – most of us fall into one naturally without even trying.  The focus herein is on some of the components of schedules that you’re promoting that can actually have a deleterious effect on babies’ and mothers’ health and well-being.

Sleep Schedules

There is no debate from me that babies need sleep – it’s why they sleep an average of 20 hours a day in the beginning (though this is highly variable).  I know this is where many of you will come out swinging because there are many articles out there touting the ill-effects of sleep problems, including night waking, and how things like offering comfort only hurt the child with respect to sleep (e.g.[5]).  Now, this is typically in reference to advocating for crying-it-out at night and working towards getting babies to sleep through the night early, despite the fact that as humans we are not biologically predisposed to that (for a review of mammalian feeding patterns and how it affects sleep, see Bed-sharing and Co-Sleeping: Research Overview by Dr. Helen Ball).

In fact, night wakings have never been a part of the Diagnostic and Statistical Manual of Mental Health Disorders under Sleep Disorders[6] because, while they may inconvenience parents, they simply aren’t real “problems”, particularly in infancy.  But what of the research linking things like night wakings to behavioural problems?  Let me say this: Third Variable Problem.  In all of this research, parents who report “sleep problems” also tend to report negative affect surrounding their child[7] (which improves with sleep training).  In contrast, in non-referred parents (i.e., those who have not sought help for their children’s sleep and do not see it as a problem), positive mother-infant interactions and dyads are related to greater night wakings, yet the night wakings are not deemed problematic and there are no behavioural repercussions associated with them[8].  In short, the evidence surrounding the notion of “sleep problems” in infancy is based solely on parental-report of problems and seems driven by the unrealistic and non-biological expectations placed on babies (and thus mothers who are expected to return to work early, etc., but that’s a topic for another day).  But some of your programs also dictate scheduled sleep with naps and night sleeps lasting a certain amount of time, regardless of whether or not your child is still sleeping.

Let me start by asking you – how do you feel if you’re not tired and are forced to lie in bed (usually alone)?  Do you get restless and find it even harder to fall asleep?  And how about when that alarm goes off to wake you up and you’re very clearly not ready to get up?  Tired and groggy for most of the day (or at least until you’ve had your morning cup of coffee)?  Even if you go to bed at a “reasonable” hour, if you can’t fall asleep right away because you’re not tired, getting up 8 hours later still sucks because you’ve probably only slept 5-6 hours.  Guess what?  The same thing applies to babies.  Forcing a baby to stay awake when they’re tired or go to sleep when they aren’t is detrimental to babies and a hurt a parent’s relationship as they can end up with a fussy, crying infant.  I’ve covered the research before (see Baby Expectations) but infants’ sleep-wake cycles take a while to develop and you do them no favours by trying to rush this.  In fact, there is some early evidence that doing this could actually put a baby a risk for SIDS.  In one study, only brief periods of sleep disruption were given to infants aged 7 to 18 weeks and cardiac effects were measured[9].   The authors found that by simply delaying sleep 2 hours just once, infants’ cardiac (heart) responses during sleep were altered in ways that could be related to SIDS.  A second review[10] examined the evidence for a link between disruption in sleep and SIDS and while there has been no research on a causal relationship, there is work demonstrating that “abnormal” sleep disruption (i.e., not natural wakings) decreases an infant’s arousal ability which has been shown in several studies to be related to SIDS.  Therefore, you should be quite careful to suggest that parents rouse their children at a specified time, or that parents should keep their infants’ awake until a certain time – whether that time is dictated by the clock or some other means.  I don’t believe that parents are aware that you may be playing with their babies’ lives.

Breastfeeding Schedules

For some reason, the antiquated notion of feeding a baby every 3-4 hours remains in favour for many of you, despite the fact that it’s no longer a recommended practice by medical professionals or lactation consultants.  The reason this practice fell out of favour was that it was found to have deleterious effects on the breastfeeding relationship and to the baby’s health.

The effects on baby are well-documented.  First, there is the effect on weight gain with infants fed on-cue gaining significantly more weight than infants fed on a schedule.  One such study examined weight gain in the first week of life in a very large cohort over a week’s hospital stay post-birth.  Three groups were considered: 4-hour feeds, 3-hour feeds, and on-cue feeding and made comparisons for small, medium, and heavy babies in order to account for the natural differences that would occur.  The findings?  As stated in the article,“The rate of gain is unquestionably greater with the self demand babies” (p. 99).  In many cases, the self demand babies were more than doubling the gain of the 4-hour scheduled babies and sometimes even doubling the gain of the 3-hour scheduled babies as well.[11]  A second Japanese study found that cue feeding was associated with lower weight loss post-birth relative to infants fed on a schedule.[12]  However, there is a study that has been cited before suggesting no difference between scheduled feeds and cue feeds.  In this study, no differences in growth from birth to 6 months was found between the two feeding groups, but in both groups, the dominant form of feeding was via formula which has a very different composition than human breastmilk and thus should not be used to form any basis of advice for breastfeeding[13].  An infant’s health is also affected by feeding schedules via a reduction in meconium passing[12] as well as higher bilirubin levels[12][14], the by-product that results in jaundice.  This means that infants who are given a scheduled feeding are more likely to develop jaundice than those who do not.

The effects of scheduled feeds extend to the entire breastfeeding dyad between mothers and their infants, which can have more global effects if mom is forced to end that relationship early, meaning her child doesn’t get the immense benefits associated with breastfeeding (see Why Is Saving Babies’ Lives Not Enough?).  In Norway, certain practices were instituted in the early 1970s in order to facilitate greater breastfeeding rates, of those were the use of on-cue feeding, as opposed to scheduled feeds, and this, along with other practices, did lead to an increase in breastfeeding rates by the early 1980s[15].  The aforementioned Japanese study found that on-cue breastfeeding led to infants receiving more breast milk on days 3 and 5[12].  Even when scheduled feeds were the norm, researchers realized the direct link between the number of feeds and a woman’s milk production.  Back in 1961, an article was published with data on how increasing the number of feeds during the day resulted in a parallel increase in milk supply for women, though it took 48 hours before the increase was noticed[16].  None of this even addresses the issues for babies on a growth spurt who typically require extra nourishment in order for their bodies to grow properly.

More generally, people have researched the high prevalence of breastfeeding problems found in industrialized and developed cultures and found that the common denominator is that we promote, what one researcher called it, nonbiological breastfeeding patterns.  The scheduling of feeds and reduction in night-time feeds do not match with what humans are biologically predisposed to require and thus there is little surprise that women’s milk productions suffer as a result[17].  Another review on breastfeeding concluded that many of the problems women face in developed nations with respect to breastfeeding stem from the arbitrary rules placed on breastfeeding, such as scheduled feeds.  The authors of the review argue that research shows that breastfeeding works best when there are no prescriptive practices in place for it[18].  In line with this, another study found that a mother’s ability to be flexible in her feeds and thus feed when the infant needs it – on-cue, not on a schedule – was related to breastfeeding success, both shorter and long-term[19].

In sum, scheduled feeds went out of practice for a reason—namely, they can harm baby and have been consistently associated with problems breastfeeding, something we know to be a problem in industrialized societies.  The only reason left for them is somehow to convenience the mother, but if she ends up unable to breastfeed as a result, how convenient was it?

Conclusions

There is nothing wrong with a generalized routine.  Having a bedtime routine where you bathe and read to your infant prior to feeding them for sleep is harmless.  Knowing how your day will generally go is harmless.  But when parents start trying to dictate their days down to the hours, regardless of whether this was “guided by baby” or set up by someone else, we start to see problems, and it should be no surprise – babies aren’t meetings or appointments, they’re people.  Especially during the first few months, a baby is constantly changing and with it, his or her needs.  Trying to force your child to eat and sleep at particular times basically ignores their individual differences because, really, no two babies are the same.  We naturally fall into routines, so what on earth would make someone feel the need to “create” one?  Does that not take away from the fun and joy of time spent with your newborn?  Why not promote parents listening to their little one in order to learn about this little person they’ve brought into the world?

I’m nearly the end of our series here, but I have one more lesson for you which will cover the idea of the external womb and how it facilitates development.  As many of you seem to write as if a baby were a full-fledged adult in need of rules and regulations, you might need some information on the biology behind infant development.

 

More from Educating the Experts:

Lesson One: Crying

Lesson Two: Needs

Lesson Three: Touch

Lesson Four: Self-Soothing



[1] Joshi P, Bogen K.  Nonstandard schedules and young children’s behavioural outcomes among working low-income families.  Journal of Marriage and Family 2007; 69: 139-156.

[2] Barnett RC, Gareis KC.  Shift work, parenting behaviors, and children’s socioemotional well-being: a within-family study.  Journal of Family Issues 2007; 28: 727-748.

[3] Boutot EA.  Developing schedules for improved behavior and independence.  In EA Boutot & M Tincani (Eds.) Autism Encyclopedia: The Complete Guide to Autism Spectrum Disorders (pp. 149-155).  Waco, TX: Prufrock Press, 2009.

[4] Fuligni AS, Howes C, Huang Y, Hong SS, Lara-Cinisomo S.  Activity settings and daily routines in preschool classrooms: diverse experiences in early learning settings for low-income children.  Early Childhood Research Quarterly 2011; doi: 10.1016/j.ecresq.2011.10.001.

[5] Sadeh A, Tikotzky L, Scher A.  Parenting and infant sleep.  Sleep Medicine Reviews 2010; 14: 89-96.

[6] American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Health Disorders – 4th Edition, Text Revision.  Washington, DC: Author, 2000.

[7] France KG.  Behavior characteristics and security in sleep-disturbed infants treated with extinction.  Journal of Pediatric Psychology 1992; 17: 467-475.

[8] Scher A.  Attachment and sleep: a study of night waking in 12-month-old infants.  Developmental Psychobiology 2001; 38: 274-285.

[9] Franco P, Seret N, Van Hees JN, Lanquart J-P, Groswasser J, Kahn A.  Cardiac changes during sleep in sleep-deprived infants.  Sleep 2003; 26: 845-848.

[10] Simpson JM.  Infant stress and sleep deprivation as an aetiological basis for the sudden infant death syndrome.  Early Human Development 2001; 61: 1-43.

[11] Salber EJ.  The effect of different feeding schedules on the growth of Bantu babies in the first week of life.  The Journal of Tropical Pediatrics 1956; 2: 97-102.

[12] Yamauchi Y, Yamanouchi I.  Breast-feeding frequency during the first 24 hours after birth in full-term neonates.  Pediatrics 1990; 86: 171-175.

[13] Saxon TF, Gollapalli A, Mitchell MW, Stanko S.  Demand feeding or schedule feeding: infant growth from birth to 6 months.  Journal of Reproductive and Infant Psychology 2002; 20: 89-99.

[14] De Carvalho M, Klaus MH, Merkatz RB.  Frequency of breast-feeding and serum bilirubin concentration.  Am J Dis Child 1982; 136: 737-738.

[15] Helsing E, Klernes U.  A silent revolution—changes in maternity ward routines with regard to infant feeding in Norway 1973-1982.  Acta Paediatrica 1985; 74: 332-337.

[16] Egli GE, Egli NS, Newton M.  The influence of the number of breast feedings on milk production.  Pediatrics 1961; 27: 314-317.

[17] Gussler JD, Briesemeister LH.  The insufficient milk syndrome: a biocultural explanation.  Medical Anthropology 1980; 4: 145-174.

[18] Woolridge MW, Phil D, Baum JD.  Recent advances in breast feeding.  Pediatrics International 1993; 35: 1-12.

[19] Bernal J.  Crying during the first 10 days of life, and maternal responses.  Developmental Medicine & Child Neurology 1972; 14: 362-372.

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Comments

  1. says

    Ok, so I have a question in regards to this. I have previously read that developmental studies have shown children under 6-8 do significantly better if they are in bed before 8pm, regardless of wake-up time or overall hours of sleep. I have read that this includes babies (but not necessarily newborns). It’s also a historic norm that children go to bed early. (Wee Willy Winky ran through town, upstairs and downstairs in his nightgown, rapping at the windows, crying at the locks, are the children in their beds? For now tis 8 o’clock. Courtesy of Old Mother Goose) now I get that when you’re sleeping 20 hours a day as a newborn *when* you sleep seems rather superfluous. But when does the whole ‘early to bed’ for good brain development officially begin? Or is the whole notion of needing to be in bed early simply predicated upon modern needs to rise early? I know sleep studies show different age groups sleep more deeply and wake more naturally at different times, so…comments? I’ve always been a strict bedtime advocate after the first 6-8 months or so. (Although that means starting bedtime at the same time, nursing as long as it takes to get them to sleep, NOT CIO. )

    (Oh, and I’m not ignoring our email coversation, I’m having difficulty with google on my cell right now. Should be getting new cell in Jan, so if nothing else I should be able to get back to you next month. I can still read them, however, so feel free to send updates on Night and Flesh if you get some reading done.)

    • says

      I can say that I’ve never read a single study that suggested children need to be in bed before 8pm regardless of wake-up time. Now, there is lots suggesting that when infants start doing the longer night sleeps and fewer naps that they need a certain amount of sleep at night, but when that comes has never seemed to matter in the research. A few things to consider though are that some infants may have problems “sleeping in” with the sun out, noises being louder, etc. and thus this may affect the time at which they need to go to sleep. Second is what you pointed out is that our society is based on early rising and so that is most likely the reason for early sleep. Finally, retrospective studies have found that gifted children tend to sleep much less and go to bed much later, suggesting that the timing it really irrelevant. My daughter is a late sleeper – often going to bed close to midnight – but she sleeps in so it’s not worrisome at all (though I’m slowly trying to change this naturally because it’s driving me mad!). I know other kids who will be out by 7am but up at 4am which sounds like torture to me, but that’s their sleep cycle. The only other reason I can think to do this is to try and force their circadian rhythm to be something in the realm of 7 or 8 to 8am or whatever instead of letting their natural rhythm form (which, as is the case with my daughter, may not be the most “convenient” type).

      I’d love to know where you read the studies though because I’d be fascinated to see the research as I can’t find it myself :) (But doesn’t mean it’s not out there.)

      • says

        This is where interests overlap. I get a fair amount of stuff on schools and education too. And inveritable the call for elementary school to begin earlier and junior/high school to begin later is based on sleep studied mentioned to have shown young children do better developementally when they are early to bed and their sleep cycle naturally wakes them early, while teenagers circadian rhythym naturally goes from late night to late morning sleep and they are more alert in the midday. The studies are always ‘mentioned’ and footnoted, but, alas, I’ve never seen a link back to the full study. it was also mentioned in the developmental guide I got from the county health office for my 1st child. It’s been mentioned in so many different things I took it as an accepted developmental truth. I don’t have any of the specific footnotes saved. I suppose if you’ve never heard of it, it very well may be one or two old studies that get drug out to attempt to convince school officials, but that really mean nothing. I’ll keep my eye out if I see it mentioned again, but I think it’s been about 2 years since the subject has come up. Although…wait, I saw it on an American Pediatrics Association website about 18 months ago, mentioned in an article on sleep for school-aged children. Maybe I’ll see if I can find that again.

        • says

          Please do let me know if you find it because I honestly have not hear that. Of course, there’s a huge confound in that most children are in some ways forced to their parents’ schedule when young because mom and dad have to get up early and that may very well influence any results. If the comparisons don’t account for these confounds, it’s hard to know what to believe :)

  2. Kel says

    With regards to school start times– I think that’s right, but a bit beside the point. I have read (in either The Baby Book by the Sears’ or in the No Cry Sleep Solution, don’t remember which one) that babies’ circadian rhythms don’t approach adult-style until they’re about ten months old. Most baby-scheduling is done much earlier than that. So while elementary-school kids may tend to wake up more in line with an earlier school time, and high school kids in line with a later start, that’s after years of practice paying attention to the sun, family rhythms, and so on.
    Glad to see the point about retroactive studies finding that gifted kids sleep less and later. My mom was comforted to learn that years ago, as both my brother and I (both gifted) were “bad” sleepers. And I’m glad to read it now, as my 7.5mo is currently pretending she’s not sleepy, though it’s 12:30am. She sleeps when she wants to, usually midnight-11am and then naps during her shifted daytime. She sleeps well and contentedly.

  3. Lisa says

    Very interesting series. You haven’t linked to the other part you mentioned on the external womb, though

  4. Lis says

    Have you seen this new study out on cross-cultural differences between parenting styles?

    http://brown.edu/Departments/Human_Development_Center/Roundtable/Harkness.pdf

    I found the part about the Dutch not reporting any sleep problems quite interesting and according to the article they are very into schedules. Not that I’m a proponent of strict schedules myself, I just found it quite interesting that such a large sample would claim to have no sleep problems.

    • says

      Very interesting. I’m curious about the strict schedules. Of course, they also bedshare at higher rates and so I wonder how that plays into it. If mom and dad go up and lie with you, that helps. And it seems they’re talking about children of a year or more, not infants. That’s a critical distinction.

      But it’s a fascinating study – thank you :)

      • Lis says

        True, it concerns kids of all ages but it’s actually not common to bedshare here. I live in Holland and we co-sleep and I have to say the locals find it quite shocking.

  5. Wombat Ch says

    Hi Tracy. After seeing your article “So You’re Going To Bottle Feed…” I found and saw some articles on http://www.chop.edu. At this page:
    http://www.chop.edu/healthinfo/mismanaged-breastfeeding.html
    It said: If your baby is a “sleepy” baby who does not cue to feed at least eight times in 24 hours, you will have to wake the baby to feed frequently – about every two hours during the daytime and evening hours and at least every three to four hours at night until weight gain improves.

    And at Dr.Sears website:
    http://www.askdrsears.com/topics/feeding-eating/breastfeeding/faqs/increasing-your-milk-supply
    It said: •Increase feeding frequency. Breastfeed your baby at least every two hours during the day. If your baby has been napping for more than two hours, wake her up for a feeding. (See Waking the Sleepy Baby.) Consider waking your baby for at least one extra night feeding, too, especially if you have a baby who sleeps for more than a four or five hour stretch at night.

    Based on your articles. I think it’s bad to wake a baby to feed, right?
    And when feeding a baby if she starts falling asleep, we should not keep her awake to drink more, just let her sleep. Right?

    Educating the Experts series are great and helpful. Thank you. :)

    • says

      The Dr. Sears topic is for increasing milk supply if it’s low in which case you do need to wake baby and getting more feeds in :)

      The issue of waking is tricky. Though generally not advised, if a child is too lethargic and not feeding well, you will need to wake him/her to drink more. The best person to speak to about your individual situation is a lactation consultant. If you’re worried!

      Thank you :)

  6. Rachel says

    So what’s the thought in older children and schedules? We’ve done on demand with babe but have a 7 year old that needs sleep for school. We adjust her bedtime and wake up alarm according to her attitude and self waking periods. For example, during a growth spurt she goes to bed earlier and wakes up later. After the spurt, she starts waking before the alarm so we let her stay up later. When should a child start having to be woke for school? When is it “healthy” to start teaching this as it’s something they need to adjust to as they become more involved in activities that are on schedules and later on with work/job. Is there a way for them to adjust and learn so that waking to go to work as an adult isn’t as difficult to do? Is there an age or development stage that this just happens?

    • says

      If a child needs to be woken then there’s something off in the schedule and sleep. A child will hopefully wake naturally – meaning s/he has had enough sleep. If your child can sleep earlier then try it, but I think that insofar as you need schedules for the day to work, you use them, but only then.

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